Rib Fractures in the Elderly

Why is it important to aggressively and appropriately manage rib fractures in elderly trauma patients?

Recently, an 82 year-old male suffered a fall from standing, striking his left posterior flank against a cinder block, sustaining fractures of the left 7^th-11^th ribs with displacement of the 8^th-11^th ribs, causing a moderate L hemopneumothorax.  After placement of a chest tube, drainage of the hemothorax, and reinflation of the L lung, the patient was then transferred to our facility “for management of his rib fractures”.  Given that this patient was going to be managed non-operatively, I found myself wondering why would this patient require transfer for such a seemingly common problem among trauma patients.  Rib fractures are present in 10% of all traumas, and in 30% of chest trauma specifically.  After assuming care of the patient, I quickly began to realize why this patient was given such a high level of attention.

According to my recent literature review, the presence of 6 or more rib fractures greatly increases the risk of death, not to mention an increased risk of pulmonary complications.^1,4  An increased number of rib fractures is more common in the elderly, who are also at a higher risk for complications.²   In one particular study, patients over age 45 with ≥4 rib fractures had a significantly longer duration of mechanical ventilation and longer hospital stay compared with younger patients.³    For patients <65, pneumonia occurs in 11 to 17%, whereas, for patients ≥65, rates up to 34 percent are reported.^2,3   One other study found that for each additional rib fracture in patients >65, the risk of pneumonia increased by 27%, and mortality increased by 19%.⁴   So, applying this knowledge to our patient, we can determine that with his 6 fractured ribs at the age of 82, his risk of pneumonia is up to 88%, and his risk of mortality is estimated at 38%.  Given the additional sequelae of a hemopneumothorax and the potential for retained blood, the patient has an increased risk of developing an empyema, as well as acute respiratory failure from decreased chest wall mechanics.  The need for initiation of proper and aggressive management of this patient suddenly became clear.

So, what does the research say is the most effective management to reduce mortality and morbidity associated with this type of injury in this age group?  The primary goals of management are pain control and pulmonary volume expansion.  This requires a multidisciplinary approach.  In a prospective study of patients with ≥4 rib fractures, a multidisciplinary clinical care pathway was associated with shorter intensive care unit and hospital stays, and lower mortality compared with those who were not in the care pathway.⁵   This pathway includes an acute pain service for pain management, respiratory therapy to improve volume expansion and assist with ventilator management if necessary, physical therapy to increase patient mobility, and nutritional support to optimize wound healing.  The patient’s level of pain, oxygenation and ventilation, and respiratory parameters should be closely monitored.  Judicious fluid resuscitation is important in the management of patients with multiple rib fractures to limit pulmonary edema in contused pulmonary tissues.⁶ 

Pain can be managed with oral analgesia or regional anesthesia, such as with epidural infusion, paravertebral block, intrapleural infusion, or intercostal nerve block.⁷   Of these, continuous epidural infusion is preferred due to its association with a shorter duration of mechanical ventilation, decreased incidence of nosocomial pneumonia, improved pulmonary function, better pain scores, and a decreased mortality risk at one year compared to those who only receive PO or IV narcotics or temporary regional blocks.

Pulmonary volume expansion may be accomplished through noninvasive means such as incentive spirometry, deep breathing, and coughing to reduce secretions, prevent atelectasis, and avoid the need for intubation.  Chest PT is likely not helpful due to its likelihood to increase chest wall pain.  A critical review of lung expansion maneuvers has recommended the use of CPAP as a secondary intervention for refractory atelectasis, but not as a primary postoperative prevention strategy, due to its increased risk of patient discomfort, gastric distension, hypoventilation, and barotrauma.⁸   However, there should be a low threshold for intubating this patient if they develop respiratory fatigue from poor chest wall mechanics in order to prevent morbidity associated with sudden respiratory decompensation.

Additional evidence-based management decisions may include the use of prophylactic antibiotics (?) for pneumonia or VATS for the evacuation of a retained hemothorax.  Further literature review also discussed the appropriateness of surgical fixation, chest wall reconstruction, and/or diaphragm transposition, which is all beyond the scope of an EM physician, but may be helpful in determining the patient disposition.

In summary, I learned that rib fractures can be viewed as either a simple “nuisance” which can be managed effectively on an outpatient basis in a young healthy adult with no comorbidities or they can be viewed as a serious life-threatening injury given the multiple sequelae that can develop as a direct result of the fractures.  I now recognize the importance of identifying the patients at risk and aggressively managing them.  Additionally, I have now discovered an evidence-based method to manage this type of injury and improve the elderly trauma patient’s chances of survival.

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